www.www.Jan K. Mokkenstorm M.D., psychiatristDirector 113Onlinej.mokkenstorm@113online.nlinfo@113online.nlCRISE - Summer I...
CRISE - Summer Institute 2012 - Montréal
The Netherlands• Climate: liberal, social, permissive.• Well developed mental health care system.• National health care in...
The problem• 1600 suicides per year• > 100.000 attempts registered• > 500.000 individuals with death wish orsuicidal ideat...
Online help may contributeto suicide prevention• Evidence shows effectivity of online therapy• Anonymity, distance and pri...
113 Online Mission:Prevention of suicide bymodern media• Provision of online treatment and support to suicidal people,thei...
Organization• 113Online FoundationIndependent new health care institute cooperating withexistent helplines and professiona...
Philosophy• We take a stando Suicide can really be preventedo We are on hope’s side• We are open and we listen:o Non judgm...
Language• We speak of “Zelfmoord”• Site: to the point, short sentences, no drama• Solution Focused dialogue– Validation of...
Typical SFT questions• In this painful situation you’ve described, what worked well?• How did you cope to get this far in ...
Innovations• Volunteer operated hotlines (chat and telephone)with 24/7 available second line of professionals• Online psyc...
www.113online.nlI’m thinking of suicide I’m concerned aboutsomeoneI’m a surviving relative I’m looking forinformationLocal...
InformationEducation SelfAssesmentHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelpCourse...
Information andeducation: clients• Explanation and validation of suicidal thoughts andfeelings (stress/entrapment model).•...
Information andeducation: carers• Explanation• Signals• Practical do’s and don’t’s• Getting help for someone• Getting help...
InformationEducation SelfAssessmentHotlinePeer supportConsultationAdviceAcute chatSelf HelpCourseCRISE - Summer Institute ...
Selftests & AutorepliesSelftest Young SIQ J(0-72)Adult BSI(0-39)Average tests per day 6 10Age 19,2 (sd 6,7) 36,6 (sd 11,8)...
InformationEducation SelfAssesmentHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelpCourse...
Content analysisbulletin board(Huisman en van Ballegooijen)• Initiator Topics– 81% Negative feelings & psychiatric complai...
InformatonEducation SelfAssesmentHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelpCourseC...
Self Help Course(Spijker, van Straten, Kerkhof,2011http://www.trialsjournal.com/content/11/1/25)• Six lessons to be downlo...
InformationEducationHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelCourseCRISE - Summer ...
Acute chat calls:use and satisfaction• On average 21,5 crisis calls per day answered• Average duration: 61 min (sd 39 min)...
Content analysisAcute chats (N= 396)A. Huisman, B. van Spijker, S. Huijboom• Nature of Problems– 41% Psychiatric symptoms ...
Acute chat:Direction of changeN=396 Worse No change BetterApprehensive/ Confident 27 6% 204 52% 165 42%Sad / Happy 20 5% 2...
Comparison Mishara studySuicide and Life-Threatening Behavior 37(3) June 20071-800: n=1431 tel. calls113: n=396 chatsWorse...
Comparison Misharasilent monitoring studySuicide and Life-Threatening Behavior 37(3) June 20071-800: n=1431 tel. calls113:...
InformationEducationHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelpCourseReferralWarmTr...
Online Psychotherapy bychat or e-mail• Anonymous, free• Solution Focused; CBT/DBT/ACT elements• Treatment manual• Trained/...
Experiences• Clients tend to be more open online.• Anonymity allows clients to share shamefulstories and ambivalence about...
Routine Outcome MonitorT2 FOLLOW-UPT1 ENDTHERAPY PROCESST0 STARTT2:BSS/SIQCES-DT1:BSS/SIQCES-DGould&ORSTherapySession orEx...
PlatformInformationEducation SelfAssesmentHotlinePeer supportConsultationAdviceBrief OnlineTherapyReferralWarmTransferHotl...
Site statsSite usage 5/10/09-20/03/12 Average per daySitevisit 730Unique visitorsPageviewsDuration3676,200:03:053Visitors ...
STEVENI discovered a new world through sharingthings I never thought I could. What makesthis possible is probably that you...
Claire 21Claire 21Being able to express what was burstinginside of me: I can’t live like this and I wantto put an end to i...
StarfishStarfishI shall never forget that time in my life when I reallyfelt I didn’t want to go on. That was an intensetim...
Adverse events• We know of 3 suicides, in 2 cases the clientwas in regular treatment as well.• Suicide attempts occur duri...
Impact on society• Suicide= 113 = help & expertise• Suicide seems to be more discussable onpolicy levels: structural fundi...
CRISE - Summer Institute 2012 - Montréal
Railway relatedcontent acute chats260 of 2443 unique acute chat callers (10,6%) refer to the railways as ameans of suicide...
Conclusions• Online help touches upon a vast unmet need amongsuicidal people, their relatives and bereaved. Internetallows...
Thank Youwww.113online.nlCRISE - Summer Institute 2012 - Montréal
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CRISE - INSTITUT 2012 - Jan K. Mokkenstorm - 113ONLINE : Education, help and intervention with people on the Internet

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Suicidal people are reluctant helpseekers. 113Online aims at lowering help seeking tresholds by offering a 24/7 online anonymous mental health care programme, including crisis support, guided self help, and online therapy. This programme is provided by professionals in close cooperation with volunteer staffed helplines by chat and telephone. In this presentation philosophy, structure, methods and preliminary results of 113Online are presented, including some of the dilemma's and problems we encountered implementing the online care programme.

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CRISE - INSTITUT 2012 - Jan K. Mokkenstorm - 113ONLINE : Education, help and intervention with people on the Internet

  1. 1. www.www.Jan K. Mokkenstorm M.D., psychiatristDirector 113Onlinej.mokkenstorm@113online.nlinfo@113online.nlCRISE - Summer Institute 2012 - Montréal
  2. 2. CRISE - Summer Institute 2012 - Montréal
  3. 3. The Netherlands• Climate: liberal, social, permissive.• Well developed mental health care system.• National health care insurance.• E-health is growing and promoted• Suicide used to be a non issue:– A free will tragedy on the personal level– Politically awkward on the policy level• No national suicide prevention strategy.CRISE - Summer Institute 2012 - Montréal
  4. 4. The problem• 1600 suicides per year• > 100.000 attempts registered• > 500.000 individuals with death wish orsuicidal ideation• How to reach out in time, effectively, on thatscale?• How to lower help seeking barriers?(Pagura et al 2009, Bruffaerts et al 2011, Gould et al 2012)CRISE - Summer Institute 2012 - Montréal
  5. 5. Online help may contributeto suicide prevention• Evidence shows effectivity of online therapy• Anonymity, distance and privacy alleviate inhibited helpseeking of suicidal people; online disinhibition effect• Low cost, large scale, highly transparent• Practical, easily blended into daily life wherever you are• Digital lifestyle, digital worldCRISE - Summer Institute 2012 - Montréal
  6. 6. 113 Online Mission:Prevention of suicide bymodern media• Provision of online treatment and support to suicidal people,their relatives and to bereaved• Improving their acces to (regular/offline) care• Making suicide discussable in society, health care, and politicsalleviating stigma and taboo.• Research & development, dissemination of knowledge andand expertise.CRISE - Summer Institute 2012 - Montréal
  7. 7. Organization• 113Online FoundationIndependent new health care institute cooperating withexistent helplines and professional crisis servicesFounders: volunteer organizations, mental health care,university, advocy• Staff:10 psychologists, 2 psychiatristst, webmaster, manager• Funding: Government grant € 830.000 annuallyCRISE - Summer Institute 2012 - Montréal
  8. 8. Philosophy• We take a stando Suicide can really be preventedo We are on hope’s side• We are open and we listen:o Non judgmental understanding and validation• We do what works:o Evidence basedo Focused at what can be done here & nowo Strengthen resilience and empowerment• We work togethero Professionals and volunteerso Online and offlineo Partnerships, affiliations; crosslinksCRISE - Summer Institute 2012 - Montréal
  9. 9. Language• We speak of “Zelfmoord”• Site: to the point, short sentences, no drama• Solution Focused dialogue– Validation of pain and problems– Praise and compliments for coping efforts/effects– Genuinely curious of possible adaptation– Endorsing and empowering solutions foundCRISE - Summer Institute 2012 - Montréal
  10. 10. Typical SFT questions• In this painful situation you’ve described, what worked well?• How did you cope to get this far in spite of all your troublesand pain?– Of what worked well, what would you want to carry forward?• If your problems would be solved enough,– how would things be better?– what would you do differently?– how would others tell, what would they see/hear?– what small step could you take to get things just a little bitin that direction?• What helped in the thinking we just did?CRISE - Summer Institute 2012 - Montréal
  11. 11. Innovations• Volunteer operated hotlines (chat and telephone)with 24/7 available second line of professionals• Online psychotherapy offered to (severely) suicidalindividuals anonymously and free• Evidence based guided self help and moderated peersupportCRISE - Summer Institute 2012 - Montréal
  12. 12. www.113online.nlI’m thinking of suicide I’m concerned aboutsomeoneI’m a surviving relative I’m looking forinformationLocal helpCRISE - Summer Institute 2012 - Montréal
  13. 13. InformationEducation SelfAssesmentHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelpCourseCRISE - Summer Institute 2012 - Montréal
  14. 14. Information andeducation: clients• Explanation and validation of suicidal thoughts andfeelings (stress/entrapment model).• Subtly framed as a non adaptive strategy• Practical adaptive self help strategies are suggested• Help seeking is advised and encouraged• Access to direct telephone/ online help is offered• Safety measures are promotedCRISE - Summer Institute 2012 - Montréal
  15. 15. Information andeducation: carers• Explanation• Signals• Practical do’s and don’t’s• Getting help for someone• Getting help yourselfCRISE - Summer Institute 2012 - Montréal
  16. 16. InformationEducation SelfAssessmentHotlinePeer supportConsultationAdviceAcute chatSelf HelpCourseCRISE - Summer Institute 2012 - Montréal
  17. 17. Selftests & AutorepliesSelftest Young SIQ J(0-72)Adult BSI(0-39)Average tests per day 6 10Age 19,2 (sd 6,7) 36,6 (sd 11,8)% Female 72% 60 %Average Score 40,7 (sd 20,7) 20,5 (sd 8,5)AutoreplyAdviceYoung AdultAbsent-Low 10 % 5 %Mild 5 % 2 %Suicidal 8 % 38 %Severely Suicidal 78 % 55 %CRISE - Summer Institute 2012 - Montréal
  18. 18. InformationEducation SelfAssesmentHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelpCourseCRISE - Summer Institute 2012 - Montréal
  19. 19. Content analysisbulletin board(Huisman en van Ballegooijen)• Initiator Topics– 81% Negative feelings & psychiatric complaints– 33% Experiences and problems with care.• Replies: 40% empathetic, 25% advice• Reaction to advice:– 52 % none, 18% not helpfull; 25% positiveMain function of bulletin board is sharing, ventilatingand acquiring support and understanding.CRISE - Summer Institute 2012 - Montréal
  20. 20. InformatonEducation SelfAssesmentHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelpCourseCRISE - Summer Institute 2012 - Montréal
  21. 21. Self Help Course(Spijker, van Straten, Kerkhof,2011http://www.trialsjournal.com/content/11/1/25)• Six lessons to be downloaded weekly• Minimal support and guidance by mail and/or telephone• CBT-based• Aimed at:o Handling negative affecto Attenuation of worrying and suicidal ruminationo Fostering adaptive cognitive patternso Lifting mood.CRISE - Summer Institute 2012 - Montréal
  22. 22. InformationEducationHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelCourseCRISE - Summer Institute 2012 - Montréal
  23. 23. Acute chat calls:use and satisfaction• On average 21,5 crisis calls per day answered• Average duration: 61 min (sd 39 min).• Average age 25,6 48% female, 15 % male, 37% ?• 63 % of callers thanked the helper spontaneously• 15 % dissatisfiedCRISE - Summer Institute 2012 - Montréal
  24. 24. Content analysisAcute chats (N= 396)A. Huisman, B. van Spijker, S. Huijboom• Nature of Problems– 41% Psychiatric symptoms and treatment– 26% Family– 13% School and work– 13% Loneliness– 12 % Relationship• 46% in some form of mental health treatmentCRISE - Summer Institute 2012 - Montréal
  25. 25. Acute chat:Direction of changeN=396 Worse No change BetterApprehensive/ Confident 27 6% 204 52% 165 42%Sad / Happy 20 5% 202 51% 174 44%Helpless / Resourcefull 60 15% 175 44% 161 41%Hopeless / Hopefull 32 8% 180 46% 184 46%Confused/Decided 30 8% 125 54% 154 39%Depressive mood 30 8% 222 56% 144 36%Desperate 27 7% 219 55% 150 38%Sustain thoughts 30 8% 220 56% 146 37%Suicide ambivalence n=121 10 8% 83 69% 28 23%CRISE - Summer Institute 2012 - Montréal
  26. 26. Comparison Mishara studySuicide and Life-Threatening Behavior 37(3) June 20071-800: n=1431 tel. calls113: n=396 chatsWorse No change Better1-800 113 1-800 113 1-800 113Apprenhensive/ Confident 11% 7% 49% 52% 38% 43%Sad / Happy 9% 5% 67% 51% 22% 44%Helpless / Resourcefull 10% 15% 41% 44% 49% 41%Hopeless / Hopefull 11% 8% 47% 46% 40% 46%Confused/Decided 10% 8% 36% 54% 52% 39%Depressive mood 7% 8% 74% 56% 18% 36%Desperate 6% 7% 77% 55% 16% 38%Sustain thoughts 8% 56% 37%Suicide ambivalence (n=121) 2% 8% 84% 69% 14% 23%CRISE - Summer Institute 2012 - Montréal
  27. 27. Comparison Misharasilent monitoring studySuicide and Life-Threatening Behavior 37(3) June 20071-800: n=1431 tel. calls113: n=396 chatsWorse No change Better1-800 113 1-800 113 1-800 113Apprehensive/ Confident 11% 7% 49% 52% 38% 43%Sad / Happy 9% 5% 67% 51% 22% 44%Helpless / Resourcefull 10% 15% 41% 44% 49% 41%Hopeless / Hopefull 11% 8% 47% 46% 40% 46%Confused/Decided 10% 8% 36% 54% 52% 39%Depressive mood 7% 8% 74% 56% 18% 36%Desperate 6% 7% 77% 55% 16% 38%Sustain thoughts 8% 56% 37%Suicide ambivalence (n=121) 2% 8% 84% 69% 14% 23%CRISE - Summer Institute 2012 - Montréal
  28. 28. InformationEducationHotlinePeer supportConsultationAdviceBrief OnlineTherapyHotlineAcute chatSelf HelpCourseReferralWarmTransferCRISE - Summer Institute 2012 - Montréal
  29. 29. Online Psychotherapy bychat or e-mail• Anonymous, free• Solution Focused; CBT/DBT/ACT elements• Treatment manual• Trained/supervised psychologists• Brief: max 8 sessions/exchanges• Average number sessions = 5• Av. number of completed therapies = 25/weekCRISE - Summer Institute 2012 - Montréal
  30. 30. Experiences• Clients tend to be more open online.• Anonymity allows clients to share shamefulstories and ambivalence about life.• Online therapeutic relations are therapeuticrelations requiring professional management.• Online solution focused therapy seems wellsuited and effective.CRISE - Summer Institute 2012 - Montréal
  31. 31. Routine Outcome MonitorT2 FOLLOW-UPT1 ENDTHERAPY PROCESST0 STARTT2:BSS/SIQCES-DT1:BSS/SIQCES-DGould&ORSTherapySession orExchangeSRST0:BSS/SIQCES-DCRISE - Summer Institute 2012 - Montréal
  32. 32. PlatformInformationEducation SelfAssesmentHotlinePeer supportConsultationAdviceBrief OnlineTherapyReferralWarmTransferHotlineAcute chatSelf HelpCourseCRISE - Summer Institute 2012 - Montréal
  33. 33. Site statsSite usage 5/10/09-20/03/12 Average per daySitevisit 730Unique visitorsPageviewsDuration3676,200:03:053Visitors Young< 18 Yr Adult> 17 Yr TotalI am suicidal 14,8 % 53,8 % 68,6 %I am worried aboutsomeone5,8 % 17,6 % 23,4%I am a survivor 1,4 % 6,7 % 8,0 %Total 21,9 78,1 % 100%CRISE - Summer Institute 2012 - Montréal
  34. 34. STEVENI discovered a new world through sharingthings I never thought I could. What makesthis possible is probably that your servicesare anonymous. Very approachable andeasily accessible. At certain moments thechats helped to pull me out of medownward spiral, and helped me focus myattention elsewhere.CRISE - Summer Institute 2012 - Montréal
  35. 35. Claire 21Claire 21Being able to express what was burstinginside of me: I can’t live like this and I wantto put an end to it! The fact that someoneis there in the midst of all my fear andanguish via chat, mail and a forum. I findthat wonderful, even though it doesn’tmake the feeling of wanting to die goaway, it still allowed me to vent. Nowthings are better, I am able to really FEEL.CRISE - Summer Institute 2012 - Montréal
  36. 36. StarfishStarfishI shall never forget that time in my life when I reallyfelt I didn’t want to go on. That was an intensetime for me. 113 offered me a place to express thisand lay it to rest. Now things are better I look backon this time including 113 and it gives mesomething to hold on to. And I see it as somethingthat no one else needs to know, due to theanonymity. This way I don’t need to be reminded ofit by something or someone later on in the futureand it prevents me being branded for life.CRISE - Summer Institute 2012 - Montréal
  37. 37. Adverse events• We know of 3 suicides, in 2 cases the clientwas in regular treatment as well.• Suicide attempts occur during calls or sessionsand have been dealt with by emergencyservices if caller/client revealed location.• Management received 3 formal complaintsregarding unmet expectations.• Bulletin board can become overheated:malignant online disinhibition effect?CRISE - Summer Institute 2012 - Montréal
  38. 38. Impact on society• Suicide= 113 = help & expertise• Suicide seems to be more discussable onpolicy levels: structural funding• Influence on media coverage in general andafter celebrity suicide.• Growing network of partner organizationsCRISE - Summer Institute 2012 - Montréal
  39. 39. CRISE - Summer Institute 2012 - Montréal
  40. 40. Railway relatedcontent acute chats260 of 2443 unique acute chat callers (10,6%) refer to the railways as ameans of suicide. In 16 cases this related to someone else. There were3 direct and positive references tot the “ I Listen” signs40Situation Number % of 260On the railway now 10 3,8%Today-yesterday 19 7,3%This week 10 3,8%Ever 27 10,3%Urge or a plan now 64 24,6%Decided against rail suicide 32 12,3%Ambivalent on rail suicide 23 8,8%CRISE - Summer Institute 2012 - Montréal
  41. 41. Conclusions• Online help touches upon a vast unmet need amongsuicidal people, their relatives and bereaved. Internetallows for large scale dissemination of effectiveinterventions.• Anonymity and autonomy are key ingredients in loweringthe help seeking threshold of suicidal people.• Experiences with online help and care are promising buteffects remain to be proven.CRISE - Summer Institute 2012 - Montréal
  42. 42. Thank Youwww.113online.nlCRISE - Summer Institute 2012 - Montréal

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